Shared Decision Making. Science versus Art of Medicine.

My 80 year old patient presented with symptoms and signs of kidney failure. I hospitalized him and asked for the assistance of a kidney specialist. We notified his heart specialist as a courtesy. A complicated evaluation led to a diagnosis of an unusual vasculitis with the patient’s immune system attacking his kidney as if it was a foreign toxic invader.

Treatment, post kidney biopsy, involved administering large doses of corticosteroids followed by a chemotherapy agent called Cytoxan. Six days later it was clear that dialysis was required at least until the patient’s kidneys responded to the therapy and began working again.

You need access to large blood vessels for dialysis, so a vascular surgeon was consulted. He placed a manufactured vascular access device in the patient’s lower neck on a Monday in the operating room. The access was used later that day for a cleansing filtration procedure called plasma exchange. The patient returned to his room at dinner time with a newly swollen and painful right arm and hand on the same side as the surgical vascular access procedure.

The nurses were alarmed and paged the vascular surgeon. His after-hours calls are taken by a nurse practitioner. She was unimpressed and suggested elevating the arm. The floor nurses were not happy with that answer since they had seen blood clots form downstream from vascular access devices. They next called the nephrologist. He suggested elevation of the arm plus heat. This did not satisfy the charge nurse who requested a diagnostic Doppler ultrasound to look for a clot. The nephrologist acquiesced and it was done quickly revealing a clot or deep vein thrombosis (DVT) in an arm vein.

I am the patient’s admitting physician and attending physician (it is unclear to me what the difference is) but I was surprised I did not receive the first or second call regarding the swollen arm. I was the first however to receive a call with the result. My first knowledge that a problem was occurring came when an RN called, “Dr. Reznick, the patient in 803 came back from dialysis with a painful swollen right arm and hand. The vascular surgeon was called but his covering nurse practitioner wasn’t concerned. The nephrologist ordered the test after we encouraged him to. There is a clot in the right brachial vein. What should we do?”

This was a new complication occurring to a frightened patient just returning from surgery, plasma exchange and hemodialysis for the first time to treat a rare aggressive disease he and his children had never heard of. One of my cardinal rules of practice is when in doubt listen to the patient, take a thorough history of the events, examine the involved body parts, look at the diagnostic studies with the radiologist and explain it all to the patient and family. I changed my leisure clothes to my doctor clothes and headed to the hospital delaying dinner, something my wife is incredibly understanding and tolerant of.

One of the perks of teaching medical students is being provided free and total access to the medical literature using the school’s library and subscription access. I searched for anything related to upper extremity deep vein thrombosis after establishing vascular access and related to his vasculitis. Three items popped up including recommendations and guidelines for diagnosis and treatment from the American College of Cardiology and the American College of Thoracic Surgeons all within the last six months. They both suggested the same things, use intravenous blood thinners for five to seven days then oral anticoagulants for three to six months or until the vascular access is removed. The risk of the blood clot traveling to the lungs is lower than in leg and pelvic DVTs but it is still 5 – 6%.

I read this while the radiologist accessed the films and reviewed them with me. Next stop was the eighth floor where the patient and his out of town visiting adult child were. I asked them what happened. They showed me the warm swollen arm and hand. I checked for pulses which were present and then color and neurological sensation which were normal. I explained that when vascular access is inserted in the large neck veins it can increase the risk of a clot forming in the arm veins resulting in arm and hand swelling. I explained that the chances of a clot traveling back to his heart and out to his lung were 5 – 6% and significantly less than DVTs in leg or pelvic veins. The treatment was explained. His nephrologist concurred as did the cardiologist. Heparin was begun.

With elevation and soaks the swelling was down by morning. He returned from dialysis that afternoon with his chin and neck all black and blue. He was bleeding profusely from the upper portion of the surgical access site. Nurses were applying compression to the area after the blood thinner was stopped and it continued to bleed. Vascular surgery was furious that heparin or any blood thinner was used for the clot.

Repeated phone calls to the vascular surgeon resulted in him angrily arriving much later placing six sutures to stop the bleeding. Heparin can lower platelet counts when antibodies to heparin cross react with platelets. His platelet count of 80,000 was sufficient to prevent bleeding. A blood test for heparin induced thrombocytopenia was drawn and he received two more units of blood products to replace what he lost. After stabilizing the patient, we realized his drop in platelets was due to the Cytoxan having its peak effect not heparin.

The patient had no further bruising or bleeding. He was dialyzed or had plasma exchange on alternating days for another week. The nephrologist wanted this done in the hospital not as an outpatient. It took one week for the reference lab to return the negative HIT (heparin induced thrombocytopenia) results clearing the heparin of causing the bleeding and bruises.

Prior to discharge I reviewed the long term oral anticoagulation recommendations of the American College of Cardiology and Thoracic Surgeons with the patient, nephrologist, cardiologist and hematologist. The nephrologist was comfortable with administering a kidney failure lower dose of eliquis. The vascular surgeon and cardiologist felt it was not necessary. The hematologist initially agreed then changed his mind. I asked each of the naysayers to explain to me how this patient differed from the patients in the many studies who comprised the data for the recommendations? They said he did not. They said they had a feeling and discussed “the art of medicine in addition to the science”.

In a rare vasculitis disease which few of us have seen frequently, I prefer the data in multiple studies to one’s clinical intuition. At discharge, I prescribed the oral blood thinner. I reviewed the pros and cons of the drug. The patient and daughter told me that based on the ambivalence of the hematologist he would stick with his aspirin rather than the oral anticoagulant.

Shared decision making appropriately allows patients to decide for themselves. If the patient develops pleuritic chest pain coughing up blood with shortness of breath from a pulmonary embolus, I will be called to provide care not my colleagues because specialists don’t admit.

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Coffee and the Healthy Heart

Two German biologists are stating there is sufficient data to claim that four cups of caffeinated coffee is the optimal daily dosage to maintain a healthy heart. Their findings were published in Plos Biology and summarized in Inverse Magazine. The scientists cite past warnings by public health officials of the danger of caffeine when given to people with heart conditions. Quite the contrary. They believe that up to four cups of coffee per day are actually therapeutic for the heart.

In their research they noted caffeine helps a protein called “p27” enter the energy producing mitochondria of heart cells making them function more efficiently. They experimented with rats comparing the mitochondrial function of old rats and young rats. When they injected the older rats with the caffeine equivalent of four cups of coffee, their aging mitochondria performed at the level of young rats’ mitochondria. They then experimentally caused the older rats to have a heart attack or myocardial infarction. Half of these heart damaged rats were injected with the equivalent of four cups of coffee and their heart cells repaired themselves at a far more rapid rate than those not exposed to that dose of coffee and caffeine.

The researchers conclude that four cups of coffee is probably the optimal daily dosage of coffee for a healthy heart. They caution that certain patients, especially those with malignant tumors, should probably avoid that much coffee because it may promote growth of blood vessels to the tumors. They additionally caution against using caffeine pills or energy drinks because their research was done with coffee.

Coffee in moderation is probably not harmful for any human adult.

Keep in mind, this biologic evidence was obtained in rats not human beings. Fortunately, I have not seen rats breaking into my local Dunkin Donuts and Starbucks craving a lifesaving nutrient.

Coffee has been associated with preventing cognitive dysfunction, preventing diabetes and now keeping your heart healthy. If you enjoy coffee, drinking it in moderation makes sense to me.

The American Cancer Society and Colorectal Cancer Screening

Colorectal cancer is the fourth most common cancer with 140,000 diagnoses in the nation annually. It causes 50,000 deaths per year and is the number two cause of death due to cancer.

Colorectal cancer screening guidelines have called for digital rectal examinations beginning at age 40 and colonoscopies at age 50 in low risk individuals. An aggressive public awareness campaign has resulted in a marked decrease in deaths from this disease in men and women over age 65.

The same cannot be said for men and women younger than 55 years old where there is an increased incidence of colorectal cancer by 51% with an increased mortality of 11%. Experts believe the increase may be due to lifestyle issues including tobacco and alcohol usage, obesity, ingestion of processed meats and poorer sleep habits.

To combat this increase, the American Cancer Society has changed its recommendations on screening suggesting that at age 45 we give patients the option of:

  • Fecal immunochemical test yearly
  • Fecal Occult Blood High Sensitivity Guaiac Based Yearly
  • Stool DNA Test (e.g., Cologuard) every 3 years
  • CT Scan Virtual Colonoscopy every 5 years
  • Flexible Sigmoidoscopy every 5 years
  • Colonoscopy every 10 years.

Their position paper points out that people of color, American Indians and Alaskan natives have a higher incidence of colon cancer and mortality than other populations.  Therefore, these groups should be screened more diligently. They additionally note that they discourage screening in adults over the age of 85 years old. This decision should be individualized based on the patient’s health and expected independent longevity.

As a practicing physician these are sensible guidelines. The CT Virtual Colonoscopy involves a large X irradiation exposure and necessitates a pre- procedure prep. Cologuard and DNA testing misses few malignancies but has shown many false positives necessitating a colonoscopy. Both CT Virtual Colonoscopy and Cologuard may not be covered by your insurer, and they are expensive, so consider the cost in your choice of screening.

I still believe Flexible Sigmoidoscopy must be combined with the Fecal Occult Blood High Sensitivity Testing and prepping.  Looking at only part of the colon makes little sense to me in screening.

Colonoscopy is still the gold standard for detecting colorectal cancer.

Controlled Substances and Schedule Drugs

The right to prescribe narcotics and controlled substances is regulated by the Federal Government. Physicians, dentists and health care providers apply for licensing with the Drug Enforcement Agency and request the right to prescribe medication from the different “schedules.” State legislatures and state medical boards regulate this further. Most people are unaware which medications and drugs are in which schedules or categories.

Schedule I – For the most part, these are substances which have no current accepted medical usage and are easily abused.

Examples are: Heroin, LSD, Ecstasy (methylenedioxymethamphetamine), Quaaludes          (methaqualone) and peyote.

Schedule II – These are substances with high potential for abuse with a risk of physical and psychological dependence.

Examples are: Vicodin, cocaine, methamphetamine, methadone, hydromorphone (dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, Ritalin

Schedule III – these are drugs with moderate to low potential for physical and psychological dependence.

Examples are: Products with < 90 milligrams of codeine per dosage unit such as Tylenol with codeine, ketamine, anabolic steroids and testosterone.

Schedule IV – These are drugs with a lesser risk for abuse and dependence.

Examples are: – Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, and AmbienTramadol.

Schedule V drugs have lower potential for abuse than Schedule IV drugs and contain limited amounts of narcotics. This would include antidiarrheal medications, antitussives, and mild analgesics. Cough medications with less than 200 milligrams of codeine per 100 milliliters such as Robitussin AC, Lomotil, Lyrica and Parapectolin.

All the medications on these schedules must be reported to E-Forcse, the Prescription Drug Monitoring Program, within 24 hours of dispensing by pharmacies. They all require the prescribing doctor to check E-FORSCE before prescribing.

Prostate Cancer, Digital Rectal Exams, PSA and Screening

The PSA blood test, to detect prostate cancer, clearly has saved lives according to numerous studies. The United States Preventive Task Force (USPTF) recognizes this but has decided that screening for prostate cancer is not a great idea in men aged 55-69. They point out the PSA can be elevated from an enlarged prostate, an inflamed or infected prostate, a recent orgasm while having sex and other causes.

Elevated PSAs led to trans-rectal ultrasound views of the prostate and biopsies of the prostate. These biopsies were uncomfortable, even painful, and often followed by inflammation and infection of the prostate. Many times the prostate biopsy was benign with no cancer detected. The USPTF felt the cost, worry, and potential side effects were a risk far outweighing the benefits of screening. They consequently came out against screening men in this age group.  Naturally this position produced a tidal wave of criticism from urologists and other.

So, the USPTF has produced new recommendations calling for patient education and making a shared decision whether or not to obtain a PSA measurement before you send it out. This is a bit confusing because we always discuss the pros and cons of a PSA before we draw it. Adult men are entitled to hear the pros and cons so they can make their own informed decision.

To complicate matters, a study out of McMaster University in Canada reveals physicians are poorly trained in performing a digital rectal exam. They cite the lack of experience coming out of school and going into training and cite numerous research studies showing a rectal exam is a low yield way to detect prostate cancer. They do not recommend performing digital rectal exams for prostate cancer screening.

This received much media hype and the blur between the efficiency of detecting prostate cancer via a rectal exam and the use of the rectal exam to detect rectal and colon disease has been lost. We perform digital rectal exams to detect prostate cancer and look at the perirectal area for disease. We test the strength and performance of the anal sphincter muscle. We feel for rectal polyps and growths and, in certain situations, test the stool for the presence of blood.

During my internal medicine training my teachers always required a digital rectal exam, stool blood test and slide of the stool as part of the exam. As trainees, we realized the invasiveness of the exam and did our best to be polite, gentle and caring. I always asked for permission first, and still do. How can you tell if something is abnormal if you haven’t performed normal exams?

Last but not least, Finesteride, a medicine used to shrink an enlarged prostate by inhibiting male hormones, has finally been shown to be protective against developing prostate cancer. A study published in the journal of the National Cancer Institute found that men taking it for 16 years had a 21 % lower incidence of prostate cancer.

Artificially Sweetened Beverages, Stroke and Dementia Risk

An observational study in the Journal “ Stroke, A Journal of Cerebral Circulation” examined the question of whether there is an a relationship between consuming “ diet” beverages with artificial sweeteners and the development of a stroke or dementia using data from the Framingham Heart Study Offspring Cohort. They looked at 2888 individuals older than 45 years of age for the development of strokes and 1484 participants over age 60 for the development of dementia. They followed the group for ten years and were able to gauge their intake of artificially sweetened beverages from food questionnaires filled out at exams. After making adjustments for age, sex, education, caloric intake, diet quality, physical activity, and smoking they found that higher consumption of artificially sweetened beverages was associated with a higher risk of strokes and dementia. This was not seen in individuals drinking sugar sweetened beverages.

In a comment section, the author acknowledged that diabetic patients had a higher risk of stroke and dementia than the general public and they consumed more artificially sweetened beverages than others. While the study did not show cause and effect it does leave us wondering just how safe these diet drinks are?

Hospital Discharges and the Handoffs

Fred Pelzman, M.D. is an experienced internist who practices in the NY Metropolitan area and trains young doctors at a well-deserved renowned academic medical center. His corporate behemoth medical system tries to engage in the latest and greatest business practice models for care, using technology and staff generally unavailable to the mom and pop medical practices that once dotted America.  Meanwhile, Dr. Pelzman cares for people compassionately while training his young disciples in an ever changing and complicated health care environment. I love reading his blog posts discussing his thoughts, concerns and efforts.

This week’s article or “post” is about the difficulty and danger entailed when a patient leaves the hospital, after being cared for by hospital based physicians, and returns to their homes and the care of their outside doctor’s. I give Dr. Pelzman much credit for taking ownership of the problem and attempting to solve it. I think there is a much simpler solution to his problem than creating a fast track computer program for patients who need to be seen quickly post discharge. It is called the telephone.

There was a time when physicians actually picked up the phone and called their colleagues and discussed the transfer of care before initiating it. During my internship and residency at the University of Miami Jackson Memorial Program; when a patient was being transferred, the receiving physician received a page resulting in a phone call from the transferring physician to discuss “the case.” The transferring physician wrote a transfer summary in the chart to be reviewed by the receiving physician. When patient’s went home, especially non-private patient’s, the handoffs were inadequate since often there was no receiving physician to communicate with.

After finishing my training and entering private care in a suburban community, the transfer of care was quite simple because most physicians cared for their own patients in the hospital and in the community so the transfer of care was smooth and seamless. This changed with the institution of “managed care” run by insurers at the request of employers and by the development of hospitalist physicians.

Employed hospital based physicians were the idea of Robert Wachter, M.D., the father of hospitalist medicine and the current director of hospital physician training at University of California in San Francisco. When he was completing his training in internal medicine he noticed that general internists in private medicine were not being paid very well in the field. He also noticed that his academic teachers, who were required by Medicare and insurers to actually spend time taking a history, doing a physical exam and writing a progress note on each patient on their teaching service if the facility was going to get paid for their care hated actually interacting with patients. They preferred to be in their research labs or teaching students and future doctors.

Hiring someone to do that work and creating a specialty gave them the freedom to go back to what they wanted to do. It also gave administration a certain amount of control over the tests ordered, medications ordered, length of stay and costs. At the same time this was occurring, “administrative and management experts” were out in the community, convincing private physicians that the solution to their low reimbursement was to stay in the office and see more patients and give up caring for hospital patients. It was deemed inefficient to cancel or delay patients in your office or clinic so you could run to the hospital or emergency room to see an acutely and seriously ill patient.

As hospitalist medicine took hold, medical and surgical specialties decided it was more efficient to use their services than to take the time to admit the patients with issues they were best trained to care for. Orthopedic surgeons stopped admitting patients to the hospital with fractures that needed surgical repair. They asked the hospitalist to do it. Oncologists stopped admitting patients with fevers and infections and abnormal blood counts as a consequence of their cancer or treatment of cancer. They asked the hospitalist to do it. Gastroenterologists stopped admitting acute gastrointestinal bleeders who needed endoscopy and cardiologists stopped admitting acute heart failure and pulmonary edema and heart attacks. These specialists preferred to be “consultants” and let the hospitalists perform the tedious medication reconciliation, admitting orders and mandated quality metrics forms and the deep vein thrombosis prevention forms. The hospitalists became their interns and medical students performing the time consuming , bureaucratic, labor intensive low paid administrative work so the specialist could arrive like the cavalry and just do their procedure and leave.

The problem is that the hospitalist didn’t know the patient. The referring doctor never called the hospitalist or ER physician to send the records and explain why the patient was coming and there was little if any communication. The same occurs when the patient leaves the hospital and is sent for post hospital care. No one coordinating care in the hospital contacts those responsible for the patient’s outpatient care to discuss a care plan. The fault lies with both the inpatient and outpatient physicians who don’t take the time to communicate.

Above anything else, the patient must come first. Picking up the phone and calling the receiving physician and discussing the nuances of the necessary care and creating a plan which is explained to the patient is in the patient’s best interests. All care givers need to remember this and create local environments, climates and systems that encourage communication between hospital-based physicians and community physicians.